Publications by authors named "Fredric O Finkelstein"

134 Publications

Overcoming barriers and building a strong peritoneal dialysis programme - Experience from three South Asian countries.

Perit Dial Int 2021 Jun 2:8968608211019986. Epub 2021 Jun 2.

Department of Nephrology, Teaching Hospital, Kandy, Sri Lanka.

The development of peritoneal dialysis (PD) programmes in lower-resource countries is challenging. This article describes the learning points of establishing PD programmes in three countries in South Asia (Nepal, Sri Lanka and Pakistan). The key barriers identified were government support (financial), maintaining stable supply of PD fluids, lack of nephrologist and nurse expertise, nephrology community bias against PD, lack of nephrology trainee awareness and exposure to this modality. To overcome these barriers, a well-trained PD lead nephrologist (PD champion) is needed, who can advocate for this modality at government, professional and community levels. Ongoing educational programmes for doctors, nurses and patients are needed to sustain the PD programmes. Support from well-established PD centres and international organisations (International Society of Peritoneal Dialysis (ISPD), International Society of Nephrology (ISN), International Pediatric Nephrology Association (IPNA) are essential.
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http://dx.doi.org/10.1177/08968608211019986DOI Listing
June 2021

ISPD guidelines for peritoneal dialysis in acute kidney injury: 2020 update (adults).

Perit Dial Int 2021 01 3;41(1):15-31. Epub 2020 Dec 3.

Yale University, New Haven, NJ, USA.

Summary Statements: (1) Peritoneal dialysis (PD) should be considered a suitable modality for treatment of acute kidney injury (AKI) in all settings .

Guideline 2: Access And Fluid Delivery For Acute Pd In Adults: (2.1) Flexible peritoneal catheters should be used where resources and expertise exist .(2.2) Rigid catheters and improvised catheters using nasogastric tubes and other cavity drainage catheters may be used in resource-poor environments where they may still be life-saving .(2.3) We recommend catheters should be tunnelled to reduce peritonitis and peri-catheter leak .(2.4) We recommend that the method of catheter implantation should be based on patient factors and locally available skills .(2.5) PD catheter implantation by appropriately trained nephrologists in patients without contraindications is safe and functional results equate to those inserted surgically .(2.6) Nephrologists should receive training and be permitted to insert PD catheters to ensure timely dialysis in the emergency setting (2.7) We recommend, when available, percutaneous catheter insertion by a nephrologist should include assessment with ultrasonography .(2.8) Insertion of PD catheter should take place under complete aseptic conditions using sterile technique .(2.9) We recommend the use of prophylactic antibiotics prior to PD catheter implantation .(2.10) A closed delivery system with a Y connection should be used . In resource poor areas, spiking of bags and makeshift connections may be necessary and can be considered .(2.11) The use of automated or manual PD exchanges are acceptable and this will be dependent on local availability and practices .

Guideline 3: Peritoneal Dialysis Solutions For Acute Pd: (3.1) In patients who are critically ill, especially those with significant liver dysfunction and marked elevation of lactate levels, bicarbonate containing solutions should be used (. Where these solutions are not available, the use of lactate containing solutions is an alternative .(3.2) Commercially prepared solutions should be used . However, where resources do not permit this, then locally prepared fluids may be life-saving and with careful observation of sterile preparation procedure, peritonitis rates are not increased .(3.3) Once potassium levels in the serum fall below 4 mmol/L, potassium should be added to dialysate (using strict sterile technique to prevent infection) or alternatively oral or intravenous potassium should be given to maintain potassium levels at 4 mmol/L or above .(3.4) Potassium levels should be measured daily . Where these facilities do not exist, we recommend that after 24 h of successful dialysis, one consider adding potassium chloride to achieve a concentration of 4 mmol/L in the dialysate

Guideline 4: Prescribing And Achieving Adequate Clearance In Acute Pd: (4.1) Targeting a weekly / of 3.5 provides outcomes comparable to that of daily HD in critically ill patients; targeting higher doses does not improve outcomes . This dose may not be necessary for most patients with AKI and targeting a weekly / of 2.2 has been shown to be equivalent to higher doses . Tidal automated PD (APD) using 25 L with 70% tidal volume per 24 h shows equivalent survival to continuous venovenous haemodiafiltration with an effluent dose of 23 mL/kg/h .(4.2) Cycle times should be dictated by the clinical circumstances. Short cycle times (1-2 h) are likely to more rapidly correct uraemia, hyperkalaemia, fluid overload and/or metabolic acidosis; however, they may be increased to 4-6 hourly once the above are controlled to reduce costs and facilitate clearance of larger sized solutes .(4.3) The concentration of dextrose should be increased and cycle time reduced to 2 hourly when fluid overload is evident. Once the patient is euvolemic, the dextrose concentration and cycle time should be adjusted to ensure a neutral fluid balance .(4.4) Where resources permit, creatinine, urea, potassium and bicarbonate levels should be measured daily; 24 h / and creatinine clearance measurement is recommended to assess adequacy when clinically indicated .(4.5) Interruption of dialysis should be considered once the patient is passing >1 L of urine/24 h and there is a spontaneous reduction in creatinine .

The use of peritoneal dialysis (PD) to treat patients with acute kidney injury (AKI) has become more popular among clinicians following evidence of similar outcomes when compared with other extracorporeal therapies. Although it has been extensively used in low-resource environments for many years, there is now a renewed interest in the use of PD to manage patients with AKI (including patients in intensive care units) in higher income countries. Here we present the update of the International Society for Peritoneal Dialysis guidelines for PD in AKI. These guidelines extensively review the available literature and present updated recommendations regarding peritoneal access, dialysis solutions and prescription of dialysis with revised targets of solute clearance.
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http://dx.doi.org/10.1177/0896860820970834DOI Listing
January 2021

Peritoneal dialysis for acute kidney injury: Equations for dosing in pandemics, disasters, and beyond.

Perit Dial Int 2021 05 11;41(3):307-312. Epub 2020 Nov 11.

Department of Medicine, 9308Università degli Studi di Padova, Padua, Italy.

Background: Peritoneal dialysis (PD) is a viable option for renal replacement therapy in acute kidney injury (AKI), especially in challenging times during disasters and pandemics when resources are limited. While PD techniques are well described, there is uncertainty about how to determine the amount of PD to be prescribed toward a target dose. The aim of this study is to derive practical equations to assist with the prescription of PD for AKI.

Methods: Using established physiological principles behind PD clearance and membrane transport, a primary determinant of dose delivery, equations were mathematically derived to estimate dialysate volume required to achieve a target dose of PD.

Results: The main derivative equation is = (1.2 × std-/ × TBW)/( + 4), where is the total dialysate volume per day, std-/ is the desired weekly dose, TBW is the total body water, and is the dwell time. can be expressed in terms of dwell volume, , by = (0.3 × std-/ × TBW) - (6 × ). Two further equations were derived which directly describe the mathematical relationship between and . A calculator is included as an Online Supplementary Material.

Conclusions: The equations are intended as a practical tool to estimate solute clearances and guide prescription of continuous PD. The estimated dialysate volume required for any dose target can be calculated from cycle duration or dwell volume. However, the exact target dose of PD is uncertain and should be adjusted according to the clinical circumstances and response to treatment. The equations presented in this article facilitate the adjustment of PD prescription toward the targeted solute clearance.
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http://dx.doi.org/10.1177/0896860820970066DOI Listing
May 2021

Providing care for patients with kidney failure over the next decade.

Kidney Int 2020 11;98(5):1062-1063

International Society of Nephrology, Brussels, Belgium.

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http://dx.doi.org/10.1016/j.kint.2020.07.022DOI Listing
November 2020

Strategic plan for integrated care of patients with kidney failure.

Kidney Int 2020 11;98(5S):S117-S134

Department of Nephrology & Hypertension, Glickman Urological & Kidney Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA.

There is a huge gap between the number of patients worldwide requiring versus those actually receiving safe, sustainable, and equitable care for kidney failure. To address this, the International Society of Nephrology coordinated the development of a Strategic Plan for Integrated Care of Patients with Kidney Failure. Implementation of the plan will require engagement of the whole kidney community over the next 5-10 years.
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http://dx.doi.org/10.1016/j.kint.2020.07.023DOI Listing
November 2020

Peritoneal Dialysis in the United States: Lessons for the Future.

Kidney Med 2020 Sep-Oct;2(5):529-531. Epub 2020 Sep 1.

Yale University School of Medicine, New Haven Home Dialysis, New Haven, CT.

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http://dx.doi.org/10.1016/j.xkme.2020.08.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568073PMC
September 2020

Reflections on the Ethics of End-Stage Kidney Disease Care in the U.S.

J Law Med Ethics 2020 09;48(3):535-537

Fredric O. Finkelstein, M.D., teaches at the Yale School of Medicine; Alan S. Kliger, M.D., teaches at the Yale School of Medicine.

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http://dx.doi.org/10.1177/1073110520958878DOI Listing
September 2020

Computerized adaptive technology for the assessment of HRQOL of PD and CKD patients.

Perit Dial Int 2020 Oct 5:896860820959961. Epub 2020 Oct 5.

12228Yale University, New Haven, CT, USA.

This study was designed as a pilot study to see whether electronic patient-reported outcome measures using computer adaptive technology (CAT) could be successfully implemented in clinics caring for chronic kidney disease (CKD) and peritoneal dialysis (PD) patients. The results demonstrate the feasibility of using CAT on an iPad to assess the symptom burden and health-related quality of life of both PD and CKD patients.
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http://dx.doi.org/10.1177/0896860820959961DOI Listing
October 2020

Challenges of access to kidney care for children in low-resource settings.

Nat Rev Nephrol 2021 01 1;17(1):33-45. Epub 2020 Oct 1.

Nationwide Children's Hospital, Columbus, OH, USA.

Kidney disease is a global public health concern across the age spectrum, including in children. However, our understanding of the true burden of kidney disease in low-resource areas is often hampered by a lack of disease awareness and access to diagnosis. Chronic kidney disease (CKD) in low-resource settings poses multiple challenges, including late diagnosis, the need for ongoing access to care and the frequent unavailability of costly therapies such as dialysis and transplantation. Moreover, children in such settings are at particular risk of acute kidney injury (AKI) owing to preventable and/or reversible causes - many children likely die from potentially reversible kidney disease because they lack access to appropriate care. Acute peritoneal dialysis (PD) is an important low-cost treatment option. Initiatives, such as the Saving Young Lives programme, to train local medical staff from low-resource areas to provide care for AKI, including acute PD, have already saved hundreds of children. Future priorities include capacity building for both educational purposes and to provide further resources for AKI management. As local knowledge and confidence increase, CKD management strategies should also develop. Increased awareness and advocacy at both the local government and international levels will be required to continue to improve the diagnosis and treatment of AKI and CKD in children worldwide.
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http://dx.doi.org/10.1038/s41581-020-00338-7DOI Listing
January 2021

Barriers to optimal peritoneal dialysis.

Semin Dial 2020 Nov 13;33(6):464-467. Epub 2020 Sep 13.

Yale University, New Haven, CT, USA.

Peritoneal dialysis in the United States is underutilized when compared to the experience in other developed countries. The reasons for this are multifactorial and include government regulatory issues, the priority of dialysis facilities, and education and training of nephrology trainees and patients. The challenges to expanding PD in the United States are discussed and strategies to overcome the barriers are outlined.
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http://dx.doi.org/10.1111/sdi.12912DOI Listing
November 2020

Peritoneal Dialysis during Active War.

Semin Nephrol 2020 Jul;40(4):375-385

Division of Nephrology, Bezmialem Vakif University, Istanbul, Turkey. Electronic address:

Armed conflict jeopardizes patient care through shortages in vital medical supplies. When health care resources are both scarce and not secure, ethically justified principles of action are required to continue the treatment of patients. Although literature exists on the allocation and treatment decisions for military health care workers and warfighters, scarce literature exist for the use of available resources for civilians living within war zones. Chronic or acute kidney disease patients requiring replacement therapies are among the most vulnerable patient population in this regard. In this article, we discuss the use of peritoneal dialysis treatment for both acute and chronic kidney disease patients during war times.
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http://dx.doi.org/10.1016/j.semnephrol.2020.06.005DOI Listing
July 2020

Pruritus as a Patient-Reported Primary Trial End Point in Hemodialysis: Evaluation and Implications.

Am J Kidney Dis 2020 07 22;76(1):148-151. Epub 2020 Apr 22.

Department of Medicine, Yale University, New Haven, CT. Electronic address:

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http://dx.doi.org/10.1053/j.ajkd.2020.01.002DOI Listing
July 2020

Development of a framework for minimum and optimal safety and quality standards for hemodialysis and peritoneal dialysis.

Kidney Int Suppl (2011) 2020 Mar 19;10(1):e55-e62. Epub 2020 Feb 19.

Department of Medicine, Yale University, New Haven, Connecticut, USA.

Substantial heterogeneity in practice patterns around the world has resulted in wide variations in the quality and type of dialysis care delivered. This is particularly so in countries without universal standards of care and governmental (or other organizational) oversight. Most high-income countries have developed such oversight based on documentation of adherence to standardized, evidence-based guidelines. Many low- and lower-middle-income countries have no or only limited organized oversight systems to ensure that care is safe and effective. The implementation and oversight of basic standards of care requires sufficient infrastructure and appropriate workforce and financial resources to support the basic levels of care and safety practices. It is important to understand how these standards then can be reasonably adapted and applied in low- and lower-middle-income countries.
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http://dx.doi.org/10.1016/j.kisu.2019.11.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7031684PMC
March 2020

Challenges for sustainable end-stage kidney disease care in low-middle-income countries: the problem of the workforce.

Kidney Int Suppl (2011) 2020 Mar 19;10(1):e49-e54. Epub 2020 Feb 19.

Department of Medicine, Yale University, New Haven, Connecticut, USA.

Prevention and early detection of kidney diseases in adults and children should be a priority for any government health department. This is particularly pertinent in the low-middle-income countries, mostly in Asia, Africa, Latin America, and the Caribbean, where up to 7 million people die because of lack of end-stage kidney disease treatment. The nephrology workforce (nurses, technicians, and doctors) is limited in these countries and expanding the size and expertise of the workforce is essential to permit expansion of treatment for both chronic kidney disease and end-stage kidney disease. To achieve this will require sustained action and commitment from governments, academic medical centers, local nephrology societies, and the international nephrology community.
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http://dx.doi.org/10.1016/j.kisu.2019.11.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7031680PMC
March 2020

Health-related quality of life and adequacy of dialysis for the individual maintained on peritoneal dialysis.

Perit Dial Int 2020 05 17;40(3):270-273. Epub 2020 Jan 17.

Department of Renal Medicine, Singapore General Hospital, Singapore.

The goal of care of the peritoneal dialysis (PD) patient should be directed at adjusting therapy to maximize the patient's health-related quality of life (HRQOL). Incorporating the routine assessments of HRQOL into the care of PD patients is important and should serve as an essential marker of the adequacy of dialysis and help the dialysis staff design the optimal treatment regimen for each patient. HRQOL is best assessed with patient-reported outcome measures (PROMs). How best to incorporate these PROMs into the routine care of the PD patient is not clear in terms of the best instruments to use, frequency of measurements, patient acceptability, and how to translate these assessments into improvements in patient care. Nevertheless, incorporating routine assessments of HRQOL into the care of PD patients is essential if the dialysis team is to provide optimal care; it is an area that is receiving increasing attention and is ripe for further study and investigation.
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http://dx.doi.org/10.1177/0896860819893815DOI Listing
May 2020

Accuracy of the estimation of and the implications this has when applying / for measuring dialysis dose in peritoneal dialysis.

Perit Dial Int 2020 05 17;40(3):261-269. Epub 2020 Jan 17.

Yale University School of Medicine, New Haven, CT, USA.

Background: Current guidelines for the prescription of peritoneal dialysis dose rely on a single cut-off 'minimal' value of /. To apply this in the clinic, this requires an accurate estimation of , the volume of urea distribution that equates to the total body water (TBW). This analysis sought to determine the accuracy to which can be estimated.

Methods: A literature search was undertaken of studies comparing TBW estimation using two or three of the following methods: isotopic dilution (gold standard), anthropometric equations (e.g. Watson formula) and bioimpedance analysis. Studies of healthy and dialysis populations of all ages were included. Mean differences and 95% limits of agreement (LOA) were extracted and pooled.

Results: In 44 studies (31 including dialysis subjects), the between-method population means were typically within 1-1.5 L of each other, although larger bias was seen when applying anthropometric equations to different racial groups. However, the 95% LOA for all comparisons were consistently wide, typically ranging ±12-18% of the TBW. For a typical individual whose TBW is 35 L with a measured / of 1.7, this translates into a range of / 1.4-2.05.

Conclusions: There are limitations to the accuracy of estimation of which call into question the validity of applying a single threshold / value as indicative of adequate dialysis. This should be taken into account in guideline development such that if a target / was deemed appropriate that this should be expressed as a range; alternatively single targets should be avoided and dialysis dose should be determined according to patient need.
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http://dx.doi.org/10.1177/0896860819893817DOI Listing
May 2020

The use of peritoneal dialysis in heart failure: A systematic review.

Perit Dial Int 2020 11 13;40(6):527-539. Epub 2020 Jan 13.

Division of Nephrology and Hypertension, Department of Medicine, 8784University of California San Diego, San Diego, CA, USA.

Heart failure (HF) is a major cause of morbidity and mortality. Extracorporeal (EC) therapy, including ultrafiltration (UF) and haemodialysis (HD), peritoneal dialysis (PD) and peritoneal ultrafiltration (PUF) are potential therapeutic options in diuretic-resistant states. This systematic review assessed outcomes of PD and compared the effects of PD to EC. A comprehensive search of major databases from 1966 to 2017 for studies utilising PD (or PUF) in diuretic-resistant HF was conducted, excluding studies involving patients with end-stage kidney disease. Data were extracted and combined using a random-effects model, expressed as odds ratio (OR). Thirty-one studies ( = 902) were identified from 3195 citations. None were randomised trials. Survival was variable (0-100%) with a wide follow-up duration (36 h-10 years). With follow-up > 1 year, the overall mortality was 48.3%. Only four studies compared PD with EC. Survival was 42.1% with PD and 45.0% with EC; the pooled effect did not favour either (OR 0.80; 95% confidence interval (CI): 0.24-2.69; = 0.710). Studies on PD in patients with HF reported several benefits. Left ventricular ejection fraction (LVEF) improved after PD (OR 3.76, 95%CI: 2.24-5.27; < 0.001). Seven of nine studies saw LVEF increase by > 10%. Twenty-one studies reported the New York Heart Association status and 40-100% of the patients improved by ≥ 1 grade. Nine of 10 studies reported reductions in hospitalisation frequency and/or duration. When treated with PD, HF patients had fewer symptoms, lower hospital admissions and duration compared to diuretic therapy. However, there is inadequate evidence comparing PD versus UF or HD. Further studies comparing these modalities in diuretic-resistant HF should be conducted.
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http://dx.doi.org/10.1177/0896860819895198DOI Listing
November 2020

Symptoms of Secondary Hyperparathyroidism in Patients Receiving Maintenance Hemodialysis: A Prospective Cohort Study.

Am J Kidney Dis 2020 03 16;75(3):373-383. Epub 2019 Oct 16.

Amgen, Thousand Oaks, CA.

Rationale & Objective: Although multiple lines of evidence suggest a negative impact of secondary hyperparathyroidism on patients with kidney failure treated by hemodialysis, it is uncertain whether patients can detect associated symptoms. The objective was to determine whether changes in parathyroid hormone (PTH) levels are associated with changes in symptoms within this patient population.

Study Design: Prospective cohort.

Setting & Participants: 165 adults with hyperparathyroidism secondary to kidney failure diagnosed, a range of dialysis vintages, and receiving regular hemodialysis from a US single-provider organization.

Exposure: Change in PTH levels over 24 weeks.

Outcomes: 19 putative symptoms of secondary hyperparathyroidism measured up to 4 times using a self-administered questionnaire that assessed severity on a 5-level ordinal scale.

Analytical Approach: Longitudinal associations between changes in PTH levels and symptom severity were assessed using generalized additive models.

Results: The 165 participants studied represented 81% of enrollees (N=204) who had sufficiently complete data for analysis. Mean age was 56 years and 54% were women. Increases in PTH levels over time were associated (P<0.1) with worsening of bone aches and stiffness, joint aches, muscle soreness, overall pain, itchy skin, and tiredness, and the effects were more pronounced with larger changes in PTH levels.

Limitations: Findings may have been influenced by confounding by unmeasured comorbid conditions, concomitant medications, and multiple testing coupled with a P value threshold of 0.10.

Conclusions: In this exploratory study, we observed that among patients with secondary hyperparathyroidism, increases in PTH levels over time were associated with worsening of 1 or more cluster of symptoms. Replication of these findings in other populations is needed before concluding about the magnitude and shape of these associations. If replicated, these findings could inform clinically useful approaches for measuring patient-reported outcomes related to secondary hyperparathyroidism.
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http://dx.doi.org/10.1053/j.ajkd.2019.07.013DOI Listing
March 2020

The Impact of Anemia Treatment on Health-Related Quality of Life in Patients With Chronic Kidney Disease in the Contemporary Era.

Adv Chronic Kidney Dis 2019 07;26(4):250-252

Department of Psychiatry, Yale University, New Haven, CT.

The treatment of anemia with erythropoietic-stimulating agents is now part of the routine care of patients with CKD with guidelines for anemia management carefully outlined by Kidney Disease Improving Global Outcomes. The treatment of anemia impacts the health-related quality of life of CKD patients, primarily affecting the domains of energy/vitality and physical functioning. Improvements in these domains occur, in general, most noticeably when hemoglobin levels are raised from below 9 g/dL to the 10-12 range, with limited improvements occurring when hemoglobin levels are increased above 12 g/dL. Importantly, individual patient responses to anemia treatment vary depending on a variety of factors and it is important to assess the impact of treatment on each patient, particularly as nephrology care moves to a patient-centered care model.
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http://dx.doi.org/10.1053/j.ackd.2019.04.003DOI Listing
July 2019

Toward Developing a Patient-Reported Outcome Measure for Fatigue in Hemodialysis.

Am J Kidney Dis 2019 08 30;74(2):151-154. Epub 2019 May 30.

Department of Medicine, Yale University, New Haven, CT. Electronic address:

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http://dx.doi.org/10.1053/j.ajkd.2019.03.425DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7424537PMC
August 2019

Evaluation of one year of frequent dialysis on fluid load and body composition using calf bioimpedance technique.

Physiol Meas 2019 06 4;40(5):055004. Epub 2019 Jun 4.

Renal Research Institute, 315 East 62nd Street, New York, NY 10065, United States of America. Author to whom any correspondence should be addressed.

Objective: The primary aim of this study was to evaluate the effect of increased frequency of dialysis (FHD) on change in fluid status and body composition using segmental bioimpedance.

Approach: Twelve stable HD patients were switched from 3 times/week to 6 times/week HD (FHD). Systolic blood pressure (SBP), body mass and body mass index (BMI) were measured pre- and post-HD. Calf resistance (R ) at 5 kHz was measured using a multifrequency bioimpedance device (Hydra 4200). Calf resistivity (ρ  =  R * area/length), normalized resistivity (CNR  =  ρ/BMI) and calf extracellular volume (cECV) were calculated. Fat mass was measured by Futrex body composition analyzers (Futrex 6100, Futrex Tech, Inc.). All measurements were performed at baseline (BL) and monthly for up to one year.

Main Results: Nine patients completed one year of FHD. Compared to BL, body weight and cECV decreased, and CNR increased significantly by the first month but did not change thereafter. SBP pre-HD decreased significantly by the end of the first month with further reduction until month 12. Additionally, antihypertensive medication decreased significantly from baseline by month 4 and remained stable from month 6 throughout the rest of the study. The post-HD CNR in five of nine patients reached the range of normal (>18.5 10 * Ohm * m kg for males and  >19.1 10 * Ohm * m kg for females) after 1 year FHD. In patients who returned to 3 times/week dialysis, CNR decreased significantly in the first week, and this was associated with increases in body weight and SBP.

Significance: Reduction of fluid overload with no alteration of body composition was observed in this study. Accordingly, improving fluid status was confirmed by reducing BP and use of antihypertensive drugs together with increase in CNR. Measurement of fluid status by CNR in hemodialysis patients is a new method to quantitatively assess hydration potentially creating a target for volume of fluid removal.
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http://dx.doi.org/10.1088/1361-6579/ab1d8fDOI Listing
June 2019

Increasing access to integrated ESKD care as part of universal health coverage.

Kidney Int 2019 04;95(4S):S1-S33

School of Medicine, Catholic University of Santisima Concepción, Concepcion, Chile.

The global nephrology community recognizes the need for a cohesive strategy to address the growing problem of end-stage kidney disease (ESKD). In March 2018, the International Society of Nephrology hosted a summit on integrated ESKD care, including 92 individuals from around the globe with diverse expertise and professional backgrounds. The attendees were from 41 countries, including 16 participants from 11 low- and lower-middle-income countries. The purpose was to develop a strategic plan to improve worldwide access to integrated ESKD care, by identifying and prioritizing key activities across 8 themes: (i) estimates of ESKD burden and treatment coverage, (ii) advocacy, (iii) education and training/workforce, (iv) financing/funding models, (v) ethics, (vi) dialysis, (vii) transplantation, and (viii) conservative care. Action plans with prioritized lists of goals, activities, and key deliverables, and an overarching performance framework were developed for each theme. Examples of these key deliverables include improved data availability, integration of core registry measures and analysis to inform development of health care policy; a framework for advocacy; improved and continued stakeholder engagement; improved workforce training; equitable, efficient, and cost-effective funding models; greater understanding and greater application of ethical principles in practice and policy; definition and application of standards for safe and sustainable dialysis treatment and a set of measurable quality parameters; and integration of dialysis, transplantation, and comprehensive conservative care as ESKD treatment options within the context of overall health priorities. Intended users of the action plans include clinicians, patients and their families, scientists, industry partners, government decision makers, and advocacy organizations. Implementation of this integrated and comprehensive plan is intended to improve quality and access to care and thereby reduce serious health-related suffering of adults and children affected by ESKD worldwide.
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http://dx.doi.org/10.1016/j.kint.2018.12.005DOI Listing
April 2019

The Association of Functional Status with Mortality and Dialysis Modality Change: Results from the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS).

Perit Dial Int 2019 Mar-Apr;39(2):103-111. Epub 2019 Feb 9.

St. Michael's Hospital, Toronto, ON, Canada

Background: Little is known about the prevalence of functional impairment in peritoneal dialysis (PD) patients, its variation by country, and its association with mortality or transfer to hemodialysis.

Methods: A prospective cohort study was conducted in PD patients from 7 countries in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) (2014 - 2017). Functional status (FS) was assessed by combining self-reports of 8 instrumental and 5 basic activities of daily living, using the Lawton-Brody and the Katz questionnaires. Summary FS scores, ranging from 1.25 (most dependent) to 13 (independent), were based on the patient's ability to perform each activity with or without assistance. Logistic regression was used to estimate the odds ratio (OR; 95% confidence interval [CI]) of a FS score < 11 comparing each country with the United States (US). Cox regression was used to estimate the hazard ratio (HR; 95% CI) for the effect of a low FS score on mortality and transfer to hemodialysis, adjusting for case mix.

Results: Of 2,593 patients with complete data on FS, 48% were fully independent (FS = 13), 32% had a FS score 11 to < 13, 14% had a FS score 8 to < 11, and 6% had a FS score < 8. Relative to the US, low FS scores (< 11; more dependent) were more frequent in Thailand (OR = 10.48, 5.90 - 18.60) and the United Kingdom (UK) (OR = 3.29, 1.77 - 6.08), but similar in other PDOPPS countries. The FS score was inversely and monotonically associated with mortality but not with transfer to hemodialysis; the HR, comparing a FS score < 8 vs 13, was 4.01 (2.44 - 6.61) for mortality and 0.91 (0.58 - 1.43) for transfer to hemodialysis.

Conclusion: Regional differences in FS scores observed across PDOPPS countries may have been partly due to differences in regional patient selection for PD. Functional impairment was associated with mortality but not with permanent transfer to hemodialysis.
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http://dx.doi.org/10.3747/pdi.2018.00094DOI Listing
January 2020

Measurement properties of the Short Form-36 (SF-36) and the Functional Assessment of Cancer Therapy - Anemia (FACT-An) in patients with anemia associated with chronic kidney disease.

Health Qual Life Outcomes 2018 May 31;16(1):111. Epub 2018 May 31.

Department of Medical Social Sciences, Northwestern University, Evanston, IL, USA.

Background: Anemia is a common and debilitating manifestation of chronic kidney disease (CKD). Data from two clinical trials in patients with anemia of CKD were used to assess the measurement properties of the Medical Outcomes Survey Short Form-36 version 2 (hereafter SF-36) and the Functional Assessment of Cancer Therapy-Anemia (FACT-An). The Vitality and Physical functioning domains of the SF-36 and the FACT-An Total, Fatigue and Anemia subscales were identified as domains relevant to CKD-associated anemia.

Methods: A total of 204 patients aged 18-80 years were included in the analyses that included internal consistency (Cronbach's alpha), test-retest reliability (intraclass correlation coefficients [ICCs]), convergent and known-groups validity, responsiveness, and estimates of important change.

Results: Both the SF-36 and the FACT-An had strong psychometric properties with high internal consistency (Cronbach's alpha: 0.69-0.93 and 0.79-0.95), and test-retest reliability (ICCs: 0.64-0.83 and 0.72-0.88). Convergent validity, measured by correlation coefficients between similar concepts in SF-36 and FACT-An, ranged from 0.52 to 0.77. Correlations with hemoglobin (Hb) levels were modest at baseline; by Week 9, the correlations with Hb were somewhat higher, r = 0.23 (p < 0.05) for SF-36 Vitality, r = 0.22 (p < 0.05) for FACT-An Total, r = 0.26 (p < 0.001) for FACT-Fatigue and r = 0.22 (p < 0.01) for Anemia. Correlations with Hb at Week 13/17 were r = 0.28 (p < 0.001) for SF-36 Vitality and r = 0.25 (p < 0.05) for Role Physical; FACT-An Total correlation was r = 0.33 (p < 0.0001), Anemia was r = 0.28 (p < 0.001), and Fatigue was r = 0.30 (p < 0.001). The SF-36 domains and Component Summary scores (p < 0.05-p < 0.0001) demonstrated ability to detect change. For the FACT-An, significant differences (p < 0.05-p < 0.0001) were observed between responder and non-responder change scores: important change score estimates ranged from 2 to 4 for Vitality and 2-3 for Physical functioning. Important change scores were also estimated for the FACT-An Total score (6-9), the Anemia (3-5), and Fatigue subscale (2-4).

Conclusions: Both the SF-36 Vitality and Physical function scales and the FACT-An Total, Fatigue and Anemia scales, are reliable and valid measures for assessing health-related quality of life in anemia associated with CKD.
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http://dx.doi.org/10.1186/s12955-018-0933-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5984470PMC
May 2018

Peritoneal Dialysis for AKI in Cameroon: Commercial vs Locally-Made Solutions.

Perit Dial Int 2018 Jul-Aug;38(4):246-250. Epub 2018 May 23.

Warren Alpert Medical School of Brown University, Providence, RI, USA

Background: Acute kidney injury (AKI) is common in low- and middle-income countries, and is associated with a high mortality. The high mortality rate is in large part due to the inability to perform dialysis in resource-limited settings. Due to significant cost advantages, peritoneal dialysis (PD) has been used to treat AKI in these settings. The costs, however, remain high when commercial solutions are used.

Methods: This is a retrospective cohort study of the outcome, and of the peritonitis rates, of patients with AKI treated with either commercially manufactured PD solutions or locally-made PD solutions. A program to treat AKI with PD was started at Mbingo Baptist Hospital in Cameroon. Between May 2013 and January 2015, solutions and connection sets were provided by the Saving Young Lives Program. From January 2015 through March 2017, solutions were locally produced and available tubing was used.

Results: Mortality in hospitalized AKI patients was 28% during the period when commercial solutions and tubing were utilized, and 33% when locally produced solutions and available tubing were utilized. In both groups, peritonitis occurred in 16% of treatment courses.

Conclusions: Locally produced PD solutions, used with locally available tubing, were used to treat AKI with PD. The mortality and peritonitis rates were similar whether locally produced or commercial supplies were used.
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http://dx.doi.org/10.3747/pdi.2017.00190DOI Listing
January 2019

Peritoneal Dialysis in Austere Environments: An Emergent Approach to Renal Failure Management.

West J Emerg Med 2018 May 5;19(3):548-556. Epub 2018 Apr 5.

Atlanta VA Medical Center, Emory University, Department of Nephrology, Atlanta, Georgia.

Peritoneal dialysis (PD) is a means of renal replacement therapy (RRT) that can be performed in remote settings with limited resources, including regions that lack electrical power. PD is a mainstay of end-stage renal disease (ESRD) therapy worldwide, and the ease of initiation and maintenance has enabled it to flourish in both resource-limited and resource-abundant settings. In natural disaster scenarios, military conflicts, and other austere areas, PD may be the only available life-saving measure for acute kidney injury (AKI) or ESRD. PD in austere environments is not without challenges, including catheter placement, availability of dialysate, and medical complications related to the procedure itself. However, when hemodialysis is unavailable, PD can be performed using generally available medical supplies including sterile tubing and intravenous fluids. Amidst the ever-increasing global burden of ESRD and AKI, the ability to perform PD is essential for many medical facilities.
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http://dx.doi.org/10.5811/westjem.2018.3.36762DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5942023PMC
May 2018

Assessing Fatigue in the ESRD Patient: A Step Forward.

Am J Kidney Dis 2018 03;71(3):306-308

Yale University, New Haven, CT.

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http://dx.doi.org/10.1053/j.ajkd.2017.10.021DOI Listing
March 2018

Impact of Regular or Extended Hemodialysis and Hemodialfiltration on Plasma Oxalate Concentrations in Patients With End-Stage Renal Disease.

Kidney Int Rep 2017 Nov 8;2(6):1050-1058. Epub 2017 Jun 8.

Department of Nephrology and Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.

Introduction: Calcium oxalate supersaturation is regularly exceeded in the plasma of patients with end-stage renal disease (ESRD). Previous reports have indicated that hemodialfiltration (HDF) lowers elevated plasma oxalate (P) concentrations more effectively compared with hemodialysis (HD). We reevaluate the therapeutic strategy for optimized P reduction with advanced dialysis equipment and provide data on the effect of extended treatment time on dialytic oxalate kinetics.

Methods: Fourteen patients with ESRD who underwent HDF 3 times a week for 4 to 4.5 hours (regular HDF; n = 8) or 7 to 7.5 hours (extended HDF; n = 6) were changed to HD for 2 weeks and then back to HDF for another 2 weeks. P was measured at baseline, pre-, mid-, and postdialysis, and 2 hours after completion of the treatment session.

Results: Baseline P for all patients averaged 28.0 ± 7.0 μmol/l. Intradialytic P reduction was approximately 90% and was not significantly different between groups or treatment modes [F(1) = 0.63;  = 0.44]. Mean postdialysis P concentrations were 3.3 ± 1.8 μmol/l. A rebound of 2.1 ± 1.9 μmol/l was observed within 2 hours after dialysis. After receiving 2 weeks of the respective treatment, predialysis P concentrations on HD did not differ significantly from those on HDF [F(1) = 0.21;  = 0.66]. Extended treatment time did not provide any added benefit [F(1) = 0.76;  = 0.40].

Discussion: In contrast to earlier observations, our data did not support a benefit of HDF over HD for P reduction. With new technologies evolving, our results emphasized the need to carefully reevaluate and update traditional therapeutic regimens for optimized uremic toxin removal, including those used for oxalate.
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http://dx.doi.org/10.1016/j.ekir.2017.06.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5733827PMC
November 2017

Time to Rethink Our Approach to Patient-Reported Outcome Measures for ESRD.

Clin J Am Soc Nephrol 2017 11 28;12(11):1885-1888. Epub 2017 Aug 28.

Psychiatry, Yale University, New Haven, Connecticut

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http://dx.doi.org/10.2215/CJN.04850517DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5672974PMC
November 2017
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